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Perchance to dream

December 1, 2011

ByJonathan Sackier

To die, to sleep; To sleep, perchance to dream—ay, there’s the rub: For in that sleep of death what dreams may come? Having learned that his uncle had murdered his father and then married mum, Hamlet loses it and contemplates suicide, but fears dreams in death may trump those during his disturbed conventional slumber. Maybe the Prince of Denmark had obstructive sleep apnea (OSA)?

Ever felt weary after a supposedly decent night’s snooze? Had your bed partner complain about your snoring? Awoken with a sore throat or headache? Maybe you can sleep anywhere, including at the wheel of your car, or, dare I say it, in the cockpit? Carrying a few too many pounds around the waist? You may have the same problem; apnea means to be “without breath”—a pretty scary concept. OSA is where one stops breathing multiple times during sleep because of impeded air flow.

The body needs oxygen—obtained by breathing in; carbon dioxide is expelled by breathing out. The route to our lungs is via the nose, mouth, and the trachea (windpipe). The soft palate (dangly stuff at the back of your throat) can become infiltrated with fat and when flat on your back it can block the airway, vibrating with each breath. Sometimes it totally occludes the passage, stopping breathing. As blood carbon dioxide levels rise, the brain gets a message to do something quickly, it demands a big intake of breath to overcome the obstruction and, with a mighty roar, your spouse jumps from his or her sleep and blood oxygen returns to normal. If repeated often during the night, one’s sleep is disturbed, cells throughout the body are oxygen-starved, and one awakes with a raspy throat, a disgruntled bed partner, and feeling drained. Time to take action.

The primary cause of OSA is obesity, so if you suspect you have the condition and are overweight, lose some excess cargo. Everyone knows that smoking is really bad for you; here’s yet another problem it worsens. Alcohol exacerbates OSA and the condition is more common in men, women after menopause, in those with a family history or a short, thick neck greater than 17 inches circumference. Diabetes, heart problems, and a sedentary lifestyle also impact your air intake valve as may other conditions like a misfiring thyroid gland.

See your doctor; after taking a medical history and performing an examination to include neck and body mass index measurements, a polysomnograph (PSG) may be ordered. This overnight evaluation of your health during sleep measures heart performance, blood oxygen, and chest and abdominal wall movements, and can either be completed at home or a “sleep lab” revealing how severe the problem is.

In mild cases, avoiding alcohol or big meals prior to sleep, using nasal decongestants, elevating the head of the bed, or avoiding sleeping on your back may help (try a body pillow or stitch a ball into your pajama jacket) as may losing some weight. However, if more serious, one can try a prosthesis to open the airway by pulling the jaw forward. Such devices are fitted by oral surgeons or sleep doctors. A range of cures are marketed on the Internet, and I advise caution and medical advice before parting with your hard-earned cash. Alternative treatments are proposed, but I cannot comment on those without supporting data.

Many are helped by CPAP machines, a mask connected to a “continuous positive airway pressure” pump that keeps the passages open and prevents snoring and OSA. Some devices merely have two levels of presssure (BPAP or “bilevel” PAP) and others adjust the pressure according to your needs (autotitrating). It takes some getting used to but if prescribed, persevere to find the correct mask, pressure, and humidity settings. Older machines were noisy but the current crop are almost silent, and with effort most people can tolerate this life-changing—and saving—technology.

Surgical options can address the root cause, obesity, as well as OSA. The first is known as “UP3,” shorthand for Uvulopalatopharyngoplasty. Now you know why we call it UP3! Here, excess tissue from the back of the throat is removed, rather like putting a pleat in a baggy waistband. Another option is maxillomandibular advancement where one’s jaws are moved forward to increase the space inside. Makes losing weight sound quite attractive, don’t you think? We know that pillars can help support a building; it turns out that they can support your soft palate also. In the pillar procedure, three tiny rods about three-quarter-inch long are inserted into the rear of the roof of the mouth, stiffening the tissues.

Truck drivers, like pilots, require medical certification for licensure. The Federal Motor Carrier Safety Administration communicates information about the risks of OSA, encouraging diagnosis, therapy, and onboard monitoring technologies. Fatigue plays a role in motor vehicle and aircraft accidents. Deferring a trip when you’re tired helps, but awareness that OSA can be a sneaky cause of fatigue should empower those of you with this problem to address it now.

To once again quote Hamlet, this is a consummation devoutly to be wish’d.